ASCs are absorbing a growing wave of higher-acuity patients, but some ASC leaders warn the infrastructure, staffing and financial systems needed to support that surge are dangerously behind.
The outpatient shift is accelerating. In its annual report to Congress released March 12, the Medicare Payment Advisory Commission found that the number of ASCs nationwide grew more than 2% per year on average between 2019 and 2024, and the volume of ASC surgical procedures per fee-for-service beneficiary increased 3.5% in 2024 alone, after growing at an average annual rate of 1.3% from 2019 to 2023.
Bruce Feldman, former administrator of Eastern Orange Ambulatory Surgery Center in Cornwall, N.Y., and founder of an ASC consulting firm, said hospitals are increasingly offloading higher-acuity cases to ASCs to free up OR capacity, without fully accounting for whether those settings can safely handle them.
“Hospitals today are pushing more and more cases that were traditionally done in a hospital setting into the ASC because they want to free up their ORs,” he told Becker’s. “But an ASC isn’t necessarily in the best interests of every patient.”
The migration of higher-acuity procedures from hospital outpatient departments to ASCs accelerated throughout 2024, according to a VMG Health report. Orthopedics, cardiology and advanced spine were identified as the primary growth drivers, fueled by technological advances and demand for lower-cost care.
But the infrastructure supporting that growth has not kept pace, said Tara Good-Young, CEO of Santa Rosa, Calif.-based PDI Surgery Center.
“Rising supply costs, escalating staffing expenses, and stagnant reimbursements are eroding financial stability, forcing a trade-off between cost containment and quality care,” she told Becker’s. “As high-acuity procedures shift to ASCs, the promise of efficiency is undermined by infrastructure that hasn’t kept pace. Demand is surging, yet the financial, supply chain and talent ecosystems remain out of sync.”
Patients with significant comorbidities, advanced age or complex procedural needs are better served in a hospital environment, Mr. Feldman said, a distinction he argues is getting lost as financial pressures drive the push toward outpatient migration.
“That envelope is being pushed right now,” he said. “We’re seeing higher-acuity cases moved into ASCs, and most ASCs are not equipped to handle that level of complexity.”
The consequences, he warned, are already beginning to show. Mr. Feldman recounted a recent personal experience: His cousin went into an ASC for a cardiac ablation, developed atrial fibrillation on the table and had to be transferred to a hospital after the anesthesiologists on site were not prepared to perform a cardioversion.
“That’s the kind of scenario we’re going to see more of,” he said.
Some ASC operators say they are already taking steps to ensure patient selection keeps pace with the influx of complex cases. Stephanie Perna, MSN, RN, Deerfield, Ill.-based SCA Health’s regional vice president of operations for Kentucky, told Becker’s the company is tightening how it evaluates patients who may be on the edge of ASC eligibility, incorporating in-person assessments for patients with borderline ASA risk to ensure appropriate placement.
Others stress that operational readiness is the prerequisite for any expansion. Andrew Lovewell, CEO of Columbia (Mo.) Orthopedic Group, said ASCs that absorb higher-acuity volume without the right infrastructure in place risk undermining both outcomes and margins.
“As an ASC, you have to be ready for expansion. Do you have the staff in place? Is your block schedule optimized where you can produce at that level?” he told Becker’s. “Let’s just get the basics right so we can deliver.”
If the trend accelerates without those guardrails, Mr. Feldman predicted an uptick in hospital transfers, complications and infection rates, outcomes he ties directly to a mismatch between patient acuity and ASC capabilities.
“ASCs are traditionally designed for patients who are under anesthesia for under an hour, undergoing minimally invasive procedures — patients who can get up, ambulate and go home,” he said. “When you start bringing in patients with more comorbidities and more complex surgeries, recovery takes longer, and you end up discharging patients at 8 or 9 o’clock at night. That’s just not conducive to good care.”
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